Comparison of terbutaline and atosiban as tocolytic agents in intrauterine repair of myelomeningocele: a retrospective cohort study.

BACKGROUND: Myelomeningocele (MMC) is a neural tube defect disease. Antenatal repair of fetal MMC is an alternative to postnatal repair. Many agents can be used as tocolytics during the in utero fetal repair such as ß2-agonists and oxytocin receptor antagonists, with possible maternal and fetal repercussions. This study aims to compare maternal arterial blood gas analysis between terbutaline or atosiban, as tocolytic agents, during intrauterine MMC repair. METHODS: Retrospective cohort study. Patients were divided into two groups depending on the main tocolytic agent used during intrauterine MMC repair: atosiban (16) or terbutaline (9). Maternal arterial blood gas samples were analyzed on three moments: post induction (baseline, before the start of tocolysis), before extubation, and two hours after the end of the surgery. RESULTS: Twenty-five patients were included and assessed. Before extubation, the terbutaline group showed lower arterial pH (7.347 ± 0.05 vs. 7.396 ± 0.02 for atosiban, p = 0.006) and higher arterial lactate (28.33 ± 12.76 mg.dL-1 vs. 13.06 ± 6.35 mg.dL-1, for atosiban, p = 0.001) levels. CONCLUSIONS: Patients who received terbutaline had more acidosis and higher levels of lactate, compared to those who received atosiban, during intrauterine fetal MMC repair.

Comparison of migration rates between traditional and tunneled adductor canal block catheters: a randomized controlled trial.

INTRODUCTION: Total knee arthroplasty is associated with significant postoperative pain. Continuous adductor canal blocks via an inserted adductor canal catheter are effective analgesia interventions with the advantage of decreasing quadriceps weakness and the potential of extending the analgesic effect. The classical adductor canal catheter insertion technique may have a high likelihood of catheter dislodgement out of the canal. The interfascial plane between the sartorius muscle and femoral artery (ISAFE) approach has the potential of decreasing the adductor canal catheter migration. The purpose of this study was to evaluate the incidence of catheter dislodgment to outside the adductor canal, for ISAFE and classical approaches. We hypothesized that ISAFE approach would result in a lower dislodgment rate. METHODS: Ninety-seven patients for unilateral total knee arthroplasty were included and randomized to either ISAFE intervention group or conventional group. The primary outcome was the incidence of adductor canal catheter dislodged to outside the adductor canal, on ultrasound evaluation, 24 hours after the surgery. Secondary outcomes were pain scores, opioid consumption and continuous adductor canal block related complications for the first 48 hours after surgery. RESULTS: The catheters placed using ISAFE approach had a lower rate of dislodgement in comparison to the control group (18.6% vs 44.9%, respectively, p=0.01), at 24 hours after surgery; and lower pain scores for rest, on the first two postoperative days. CONCLUSIONS: ISAFE group had a significantly lower rate of dislodgement at 24 hours. The continuous adductor canal block analgesic benefit for knee arthroplasty depends on the position of the tip of the catheter inside the adductor canal.

Effectiveness of preoperative thoracic epidural testing strategies: a retrospective comparison of three commonly used testing methods.

PURPOSE: Thoracic epidural analgesia (TEA) is a well stablished technique for pain management in major thoracic and abdominal surgeries; however, it has considerable failure rates. Local anesthetic (LA) administration and subsequent assessment of sensory block through physical examination (e.g., decreased temperature perception determined via an LA temperature dissociation test [LATDT]) has been the historical standard for evaluation of thoracic epidural placement. Nevertheless, newer methods to objectively evaluate successful placement have recently been developed, e.g., the epidural electrical stimulation test (EEST) and epidural pressure waveform analysis (EWA). The purpose of this study was to evaluate the effectiveness of preoperative TEA catheter testing (LATDT, EEST, and EWA) on reducing TEA failure. METHODS: After obtaining an institutional research ethics board approval for a retrospective study, we conducted a single-institution retrospective review on all TEAs performed between January 2016 and December 2021. Patients were assigned to one of four groups based on the performed test method to verify the placement of the TEA catheter: no test, LATDT, EEST, and EWA. A TEA was deemed successful if it provided bilateral dermatomal sensory block to ice test in the postoperative period, and was used for patient analgesia for at least 24 hr. RESULTS: One thousand two hundred and forty-one patients submitted to preoperative TEA were included. Twenty-eight patients were excluded. Tested and untested epidurals had failure rates of 3.8% (95% confidence interval [CI], 1.8 to 6.2) and 11.5% (95% CI, 5.2 to 17.1), respectively (P < 0.001). CONCLUSION: Objective preoperative testing after placement of thoracic epidurals was associated with a reduction in failure rates.

RéSUMé: OBJECTIF: L'analgésie péridurale thoracique (APT) est une technique bien établie pour la prise en charge de la douleur dans les chirurgies thoraciques et abdominales majeures; cette modalité entraîne cependant des taux d'échec considérables. L'administration d'anesthésique local (AL) et l'évaluation subséquente du bloc sensitif par un examen physique (p. ex. diminution de la perception de la température déterminée par un test de dissociation de la température après l'AL [LATDT]) ont constitué la norme historique pour l'évaluation du positionnement de la péridurale thoracique. Néanmoins, de nouvelles méthodes permettant d'évaluer objectivement le positionnement réussi ont récemment été mises au point, par exemple le test de stimulation électrique péridurale (EEST) et l'analyse de la forme d'onde de pression péridurale (EWA). L'objectif de cette étude était d'évaluer l'efficacité des tests préopératoires de cathéters d'APT (LATDT, EEST et EWA) sur la réduction des échecs d'APT. MéTHODE: Après avoir obtenu l'approbation d'un comité d'éthique de la recherche de l'établissement pour une étude rétrospective, nous avons réalisé un examen rétrospectif monocentrique de toutes les APT réalisées entre janvier 2016 et décembre 2021. Les patient·es ont été assigné·es à l'un des quatre groupes en fonction de la méthode de test utilisée pour vérifier l'emplacement du cathéter d'APT, soit : aucun test, LATDT, EEST et EWA. Une APT a été jugée efficace si elle a fourni un bloc sensitif dermatomal bilatéral au test de glace en postopératoire et a été utilisée pour l'analgésie pendant au moins 24 heures. RéSULTATS: Mille deux cent quarante et un·e patient·es soumis·es à une APT préopératoire ont été inclus·es. Vingt-huit personnes ont été exclues. Les péridurales testées et non testées présentaient des taux d'échec de 3,8 % (intervalle de confiance [IC] à 95 %, 1,8 à 6,2) et de 11,5 % (IC 95 %, 5,2 à 17,1), respectivement (P < 0,001). CONCLUSION: Les tests préopératoires objectifs après la mise en place de péridurales thoraciques ont été associés à une réduction des taux d'échec.

Lung ultrasound versus chest computed tomography for pregnant inpatients with COVID-19.

PURPOSE: To compare lung ultrasound (US) and computed tomography (CT) in the assessment of pregnant women with COVID-19. METHODS: Prospective study comprising 39 pregnant inpatients with COVID-19 who underwent pulmonary assessment with CT and US with a maximum span of 48 h between the exams. The thorax was divided into 12 regions and assessed in terms of the following: the presence of B-lines (>2), coalescent B-lines, consolidation on US; presence of interlobular thickening, ground glass, consolidation on CT. The two methods were scored by adding up the scores from each thoracic region. RESULTS: A significant correlation was found between the scores obtained by the two methods (rICC = 0.946; p < 0.001). They were moderately in agreement concerning the frequency of altered pulmonary regions (weighted kappa = 0.551). In US, a score over 15, coalescent B-lines, and consolidation were predictors of the need for oxygen, whereas the predictors in CT were a lung score over 16 and consolidation. The two methods, US (p < 0.001; AUC = 0.915) and CT (p < 0.001; AUC = 0.938), were fairly accurate in predicting the need for oxygen. CONCLUSION: In pregnant women, lung US and chest CT are of similar accuracy in assessing lungs affected by COVID-19 and can predict the need for oxygen.

Plasmatic catecholamines after neuraxial labour analgesia: A randomised controlled trial comparing epidural versus combined spinal-epidural.

BACKGROUND: Combined spinal-epidural technique (CSE) for labour analgesia has been associated with fetal bradycardia and uterine hypertonia when compared with epidural analgesia (EA), possibly due to a decrease in epinephrine levels following neuraxial anaesthesia. However, there are no recent studies comparing plasmatic catecholamines levels between those two techniques. This study aimed to compare CSE versus EA regarding pre- and post-analgesia catecholamines levels, uterine tone and fetal heart rate. PATIENTS AND METHODS: Randomised clinical trial with 47 labouring patients divided in two groups (CSE and EA). Primary outcome was plasmatic catecholamine measurements before and after neuraxial block. Secondary outcomes were fetal heart rate changes, uterine hypertonia, hypotension episodes, pain relief and fetal outcomes. RESULTS: For CSE group, the median decrease of plasmatic epinephrine was 0 pg/mL [(-) 480-(+) 41] and for norepinephrine was -21 pg/mL [(-) 2507-(+) 94]. For EA group, the median decrease for epinephrine was 0 pg/mL [(-) 326-(+) 15] and for norepinephrine was -5 pg/mL [(-) 190-(+76)]. There were no differences between groups (p = 0.96 and p = 0.63 for epinephrine and norepinephrine, respectively). There were no differences for secondary outcomes. CONCLUSIONS: There was no evidence of a more significant decrease of catecholamines with CSE when compared with EA. Catecholamines decrease theory may not be valid for modern labour analgesia techniques.

Continuous peripheral nerve block for upper limb ischemic pain: a case report.

Peripheral Arterial Obstructive Disease (PAOD) may course with severe ischemic pain. In low-income health systems, patients may wait for vascular surgery. Continuous peripheral nerve block may be an effective alternative, with fewer side effects, in this scenario. A female patient with acute arterial obstruction of upper limb evolving with severe ischemic pain. She was submitted to a continuous infraclavicular brachial plexus block, which led to a satisfying pain control until the amputation surgery. The early postoperative period evolved with good pain management. This approach may be effective and safe as an analgesia option for ischemic pain.